1245361658 NPI number — FAMILY VISION CARE LLC

Table of content: (NPI 1245361658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245361658 NPI number — FAMILY VISION CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY VISION CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SALLY M. FIFE, OD
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245361658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42420-2751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-827-8681
Provider Business Mailing Address Fax Number:
270-826-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42420-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-827-8681
Provider Business Practice Location Address Fax Number:
270-826-7687
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FIFE
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-827-8681

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000190215 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 410009178 . This is a "PALMETTO GBA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77903672 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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